|
Gg Ir,NFRA 1,1NSFR17C'I10N%k
<br /> d. One FORM 1 ,all b,comp lctcd fOr all NEW PF'Risirns, PIr12 I'I°01ANGES or any-FAC°II.TI"Y1ST11,'
<br /> 2, SUBMUONLY ONE(1)FOR 'A"for a 'Cacifiiv/Site, regardless of the number of tanks located at the site,
<br /> 3. „ _This form should tat e:oample,wd by cither the P] fl' PPLIC`.ANI'or the LOCAL AGENCY UNL9r?F2(iltOUND I'ANK
<br /> 4 'Pleasicitype or print clearly all requested information.
<br /> 5. 1"se a hard point vri,Wlo cnSfr sea cra, you are making 3 copies.
<br /> 11 c tp OF FRM-'MARK ONLY DISI, T.W'
<br /> t, dark an (X) in tbc, box next to the nem that best describes the tcason the form is being coniplcted.
<br /> L F C"IlYI /SrIl, INFURMN11ON&ADDRE&S(MUSh 131,,C.OMPI ,11'I;I)
<br /> 1. Record name and addiess(physical location)of the underground tank(s).
<br /> I01 : Address MUSI'have=a valid physical location including city,state,and yip code.
<br /> P�0.BOX NUMBER ARE NUl'ACCETIABIA!
<br /> Include nc<a=res€cross street and name of the operator.
<br /> 2, Phone number must have ata area coda:, If the night number is the sansae,write"-SAME" in proper location.
<br /> 3. Check the approodate box for`YYPF OF BUSINESS CIWNEI SHIP(ea. C;£1RPORA'11I0Isa, Il,�T>1VI1 UAL,etc,)
<br /> 4. Check the app ornate bt)x for"INPI:i OF BUS.'.. ES'S.
<br /> 5. If Facility Site is located o r land within ar indian reservation or other in€9ian trust lands,check the box marked "Y FYS,
<br /> 6, Indicate the NUNIJBF of'1'AN S at this SO'I'L.
<br /> 7. Record the I3.P.A. 11) #r or write ";aONUi `in the space providc(L
<br /> I9, skrlt.aPEKIFY OWNER I I t lf•.VA'1"l0N&ayDDR S(MUST'BU-1(`O?v#I'1111$1))
<br /> 1. Complete all items in this section, unless all items are the same as SFC7l0N 1; if the same,write ". ME AS Sm?"across
<br /> this section. I3e seers to check 1'12€)I'[I;R Y 0ti13IZSIillP I`Y1'L`1 box.
<br /> I:TI.'CANIC C)' NE"I Z 11VI?CDl$MYVI`1C:)N&AI)1)RE&S I.I;tiI'1317 C O PLE11ar'))
<br /> 1. Complete all items in this section, unless all items are the same as SIIC FIC)N 1; If the:same,write "SAME AS Sl'u"
<br /> across this sect on. Be stare to chcck'FANK OWNERS1111"`I'YPI?box.
<br /> IV X)ARD OF H3CTti1,ZUT N U I-s I OR Cal'I FII ACyC OUNI" 1JMBE,R(MUS-1-1111 C OMPIAN1'0)
<br /> c,r}our Board of 1 1qcia'srcanon (110F)1 °rI's'lortage fee account noanbcsr which isrequired before your permit application can
<br /> be processed. Registration. with the 110 will ensure that you will receive a quarterly storage fee return in reporting the Sf) K)Ea
<br /> (6 milk)per gallon fee dace can the number of gallons placed in your t STs. ':Che BOU,will code persons exempt from paving the
<br /> storage fee so returns will not he shat. If you do not have an account number with the BOF'sir if you have any quest€ons
<br /> regarding the fee or excnrptions,please call the I30I at 916-1,39-2582 or unite to the BOE at the following address: Board of
<br /> dxlualication. Fnvironnnc srtat t'ce.s Unit, R0, Dox 942879,Sacramento, C A,94279- )1.`
<br /> V. LEGAL NC 3` I( IT N AND BILUNGIC S.S
<br /> 1. Check ONE BOX for the address that will be used for IXYI11 LFX;AL AND BILLING CIITFI(W1ION
<br /> AFPr,IcANr mun SIGN ANI)II `11,1111 FURM AS 1N1)I(WIT'D.
<br /> INS`' LY 1'1t1N FOR'nTE LOC LC1 a'NCIFS'
<br /> .1'he county and jurisdi6on a umbers arc:predetermined and can be obtained by calling the State Board(916)739-242I. The
<br /> c acdny number ma,Y be aa� = eel by th h-wal Age c however, this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prfer4'he ;
<br />
|